Provider Demographics
NPI:1417909102
Name:PETERSON, CAROL E (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:E
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5800 FOREMOST DR SE STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7062
Mailing Address - Country:US
Mailing Address - Phone:616-954-9800
Mailing Address - Fax:
Practice Address - Street 1:7 ATKINSON DR
Practice Address - Street 2:SUITE 115
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1953
Practice Address - Country:US
Practice Address - Phone:231-845-2270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050870207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1105610461OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MIC39622Medicare UPIN
MI383322171OtherTAX ID
MIP00463146Medicare PIN
MI0P20480003Medicare PIN
MI4831985Medicaid